The courage, dedication, and self-sacrifice of frontline healthcare staff, especially during the COVID-19 pandemic, are nothing short of heroic. However, this work takes a serious toll. A study of the psychological well-being of healthcare providers treating COVID-19 patients in China indicates significant mental health concerns. Of 1257 health care workers in 34 hospitals in multiple regions of China 50.4% reported symptoms of depression, 44.6% symptoms of anxiety, 34.0% symptoms of insomnia, and 71.5% psychological distress (Lai et al, 2020). Clearly interventions to support frontline healthcare workers must be implemented during and after this pandemic.
Coping with trauma is extraordinarily challenging. Anxiety, fear, sadness, and anger are normal reactions to tragic and catastrophic life events. We are battling an unprecedented pandemic. As a society, not only is our health threatened but our social, emotional, and financial resources as well. Encountering uncontrollable events and threats day after day leaves us feeling powerless and can put our psychological health at risk. While we must put intense emotions aside during daily tasks in order to function, true resilience (APA Help Center, 2005) involves acknowledgement and awareness of how our experience is impacting us, and active coping in this moment (Hobfoll et al, 2007).
Active coping means making focused efforts to: Control what you can, take care of your body, actively calm, connect with others, communicate emotions and experiences, evaluate your thinking, find meaning, look forward, and reach out for professional help when you need it. Ability to effectively, purposefully engage in these activities is the foundation of resilience. Active coping is a continuing process, which must be practiced each day to create the best possible life under the circumstances.
The following strategies are drawn from evidence-based interventions, including cognitive behavioral therapy (Flynn & Warren, 2014), dialectical behavioral therapy (Reutter, 2019; Linehan, 2014), and acceptance and commitment therapy (Twohig, 2017; Eifert, 2005)., which have empirical support for efficacy in treating both depression and anxiety associated with trauma.
Control What You Can: Let Go of What You Can’t: Lack of predictability, uncertainty about the future and concerns about our ability to solve problems leave us feeling powerless. We need to acknowledge that we do not have control of a great deal right now, but there are things that we can control.
To the extent possible, plan and carry out consistent daily routines (Feise, 2002) which ground you, give a sense of self-efficacy, and engage you in what is healthy for you. Particularly in times of anxiety people benefit from structure, predictability, and focus on goals.
Take Care of Your Body: Having energy is essential for meeting the challenge of coping in our current situation. Get Adequate Sleep; Eat nutritious food regularly and hydrate; Avoid excessive sugar, caffeine, and alcohol; Get exercise each day (Dunn et al, 2001); Monitor and pace yourself – be mindful of your physical and emotional state. Take breaks when needed
Actively Calm: Use distress tolerance activities to calm. Breathe: Take time to focus on your breathing. Find a quiet place to sit or lie on your back. Breathe in for a count of 4 and out for a count of 8. Be mindful of the sensations of the breath coming in and going out. Set other thoughts aside. Do this 10 times. Focus on your breathing while walking. Determine the number of steps you take while exhaling. Breathe naturally for a bit, then increase the length of your exhalation by one step. Do this 10 times increasing your exhalation each time, inhaling naturally. Then return to your normal pattern.
Take a Break from the Stress: Push the situation away, refusing to think about the painful aspects for a while. Censor ruminating.
Self-soothe Through Your Senses: Be mindful of one soothing sensation as you experience it. Vision: Look at nature (flowers, rain, sky), a flickering candle; go to a virtual museum. Hearing: Listen to nature; music; go to a virtual concert; sing. Smell: Use nice smelling lotion; light a scented candle; bake; smell the air and flowers outdoors. Touch: Bathe/shower; surround yourself with a soft blanket; put a cool washcloth on your forehead; feel the breeze or sun on your face.
Experience Opposite Emotions: Create opposite emotions to your negative emotions with books, movies, music.
Encourage Yourself: Repeat: “I can stand it”, “This will end”, “I will make it out of this”, “I’m doing the best I can do.”
Connect with Others: You may have the impulse to detach and become less emotionally available and communicative with others. You will need time on your own to process your experiences but do not walk alone with these burdens. Social connection and a sense of community efficacy, when living through traumatic situations, are essential to resilience (Taylor, 2011). However, this is difficult during a pandemic. Physical distancing keeps us apart. Health care workers fear bringing the virus to their families. Others fear contact with those treating patients with COVID-19. Traumatic events are surreal and so far outside the norm that healthcare workers develop changes in their worldview, which family may not understand. All of this impedes the necessary feelings of connection. We need to be creative. At work: Emphasize partnership and teamwork; Seek consultation with peers; Seek supervision; Avoid working alone for lengthy periods. At home: Make it a priority to reconnect with your core social group each day, to have a conversation, share an activity, or just be around each other; Plan activities with family and friends, both those in your home and those elsewhere. Be creative (Remote movies, trivia, painting, cocktail parties); Deepen your relationships with those you love. Try new activities (e.g., each family member or friend chooses an activity they enjoy, and everyone tries it). Connect in a way that is most comfortable, without judgment.
Communicate Emotions and Experiences: Resilience is associated with the ability to communicate feelings, thoughts, and experiences openly. It is relatively common for healthcare workers to prioritize the needs of others over their own and to feel there is a stigma associated with expressing emotions to others. Engaging with feelings rather than pushing them down is the only way to cope with them. Journal to record and process your experiences. You may be concerned that your friends or family would be uncomfortable or afraid if you talked to them about your experiences in the hospital or that they would not understand. Of course, use your best judgment but maybe try them. They may not fully understand but may be a good support and even be helped by the sense of agency they gain by supporting you. Remember, there is great value in communicating about other emotions and experiences, too. Talk to and share your experiences and emotions with your coworkers. Focus on describing your feelings without judging them. Avoiding or suppressing negative emotions only strengthens them. If you push them down, they will pop out in another way at another time. Engage humor, “another of the soul’s weapons in the fight for self-preservation” (Frankl, 2006).
Evaluate Thoughts: The core premise of Cognitive Behavioral Therapy teaches that the way we react to a situation is more related to how we think about the situation than to the situation itself. Our thoughts drive our feelings and often our behaviors. Unrealistic thoughts can produce greater distress.
Ask Yourself: Am I thinking rationally or is my thinking driven by emotion rather than evidence? Am I balancing emotion (anxiety/vigilance, compassion) with rational thought?
It is common to wonder, “Am I doing everything I possibly can do for my patient? Am I doing enough? Am I doing the right thing and making the right choices? How vulnerable am I and will I infect my family?”
In answering these questions try not to engage in irrational or destructive thinking such as, “My contribution should be to work all the time. Taking care of patients is more important than my needs and it would be selfish to rest. I am the only one who can do this. There is danger to my family and me and there is nothing I can do about it.”
Engage in positive self-talk such as, “I have done everything that is reasonably possible. There are situations I cannot change. I can focus my anxiety on what I know to be actual threats and not over generalize my fear. I can invest my efforts in what is within my power.”
Know that your feelings and concerns are valid while understanding what you can control and ways you can contribute 1) to your patients’ health without feeling unrealistically responsible for the lives of patients and 2) to protecting the health of your family and yourself.
Find Meaning: In times of crisis it is possible to find a new appreciation for life. Where concerns about our physical and economic survival consume us we can also find an opportunity to evaluate priorities. Reflect on what has importance and is of value to you. Practice gratitude for the blessings in your life. Engage in meaningful activities. Adversity can be an opportunity for personal and social growth. Focus on what it means to you to be human. Consider activities which emphasize creativity, humor, ingenuity, the arts, physical exercise, emotional insights, family, religion, whatever gives your life meaning.
Look Forward: The ability to make future plans and to be goal-directed in carrying them out is linked to hope and resilience. Make plans for the short-term future. What are you looking forward to that’s happening soon? (an online exercise class? – family game night? – reading a good book? – a short walk at the end of the day? – learning a new skill?). Although we do not know when, this crisis will pass. Imagine the future when it does.
Reach Out for Professional Help When You Need It: If your feelings become overwhelming or you feel that you need someone else with whom you can express and process your emotions and experiences, reach out for professional support.
Correspondence concerning this article should be addressed to Michelle A. Dunn, Montefiore Einstein Center for Autism and Communication Disorders, 6 Executive Plaza Suite 297, Yonkers, New York 10701, 914-375-4898, MDunn@montefiore.org.